Provider Demographics
NPI:1265615330
Name:MCDONOUGH, RORY DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:RORY
Middle Name:DANIEL
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15051 S. TAMIAMI TRAIL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908
Mailing Address - Country:US
Mailing Address - Phone:239-437-8810
Mailing Address - Fax:239-313-2555
Practice Address - Street 1:7331 GLADIOLUS DRIVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-437-8810
Practice Address - Fax:239-437-8875
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104255363AS0400X
FLPA9104255363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAJ244YMedicare PIN